Healthcare Provider Details

I. General information

NPI: 1972349322
Provider Name (Legal Business Name): AMANDA MARIE SOTO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 10/25/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 W WEST COVINA PKWY
WEST COVINA CA
91790-2703
US

IV. Provider business mailing address

1147 W BADILLO ST APT G
COVINA CA
91722-4176
US

V. Phone/Fax

Practice location:
  • Phone: 626-960-4844
  • Fax:
Mailing address:
  • Phone: 626-823-9305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: